OVERVIEW OF LIVER DISEASE AND LIVER FUNCTION TESTS

Question 1

What are the two vascular inputs into the liver?

Answer 1

The portal vein

The hepatic artery

Question 2

What does the portal vein carry?

Answer 2

Anything absorbed via intestine

Question 3

What is first part metabolism?

Answer 3

The fact that all medication will going via the liver and will begin to be metabolised before going to the rest of the systemic circulation via the heart

Question 4

What makes up the common hepatic duct?

Answer 4

The left and the right hepatic ducts

Question 5

What does the common hepatic duct join with at its distal end?

Answer 5

The cystic duct coming from the gall bladder

Question 6

What do the common hepatic duct and the cystic duct join to form?

Answer 6

The common bile duct.

Question 7

Where do the endocrine products of the liver get put into the circulation?

Answer 7

The hepatic vein

Question 8

What is the exocrine product made by the liver?

Answer 8

Bile

Question 9

Where is bile stored?

Answer 9

Gall bladder

Question 10

How does bile get from the liver to the gall bladder?

Answer 10

It travels down the common hepatic duct and then retrogradely up the cystic duct

Question 11

What are the cytotoxic blood factors of the liver?

Answer 11

AST (aspartate aminotransaminase)
ALT (alanine aminotransferase)
Albumin
PT

Question 12

What are AST and ALT and why can they be used to recognise liver disease?

Answer 12

They are enzymes in the hepatocytes so when the hepatocytes die they are released into the circulation. This is similar to the cardiac enzymes that are used as markers of cardiac muscle death.

Question 13

Will you always have high AST and ALT in liver failure?

Answer 13

No in the same way that you don’t see prolonged raise in troponin with heart failure following an MI.

Question 14

Broadly, what does elevated AST and ALT signify?

Answer 14

Inflammation in the liver

Question 15

Does AST have high or low specificity for the liver?

Answer 15

Low specificity

Question 16

Which hepatocyte is AST found in?

Answer 16

Periportal hepatocytes.

Question 17

Does ALT have high or low specificity for the liver?

Answer 17

High specificity

Question 18

Will AST and ALT be elevated in chronic liver disease?

Answer 18

Often not. They are markers of acute injury.

Question 19

What do AST and ALT tell you about residual function?

Answer 19

Nothing, they are purely markers of acute injury.

Question 20

When AST and ALT start coming down, having been raised, is this always a good thing?

Answer 20

No. It could be a good thing because it could mean that the thing causing liver damage is no longer there, or no longer damaging the liver.
However, it could also mean that there are now significantly fewer hepatocytes to damages, indicative of nearing end stage liver failure.
AST and ALT tell you nothing about residual function.

Question 21

Where is albumin made?

Answer 21

Liver

Question 22

What is low albumin usually indicative of?

Answer 22

Chronic liver injury

Question 23

Will albumin decrease in acute liver injury?

Answer 23

No. Because it has 20 day half life, so takes a while for levels to decrease.

Question 24

What does an elevated INR tell you about whether liver injury is acute or chronic?

Answer 24

It doesn’t. INR may be elevated in both.

Question 25

What is the most sensitive part of the liver function tests in terms assessing injury?

Answer 25

INR. This will be the first thing to change with acute or chronic injury.

Question 26

What are the clotting factors produced in the liver that will contribute to the elevated INR in liver injury?

Answer 26

``` 1 2 5 7 9 10 ```

Question 27

Does INR tell you the extent of liver injury?

Answer 27

Yes, unlike AST and ALT, INR is a good marker for residualt function.

Question 28

Other than liver disease, what else might cause a patient to have an elevated INR?

Answer 28

Drugs such as Warfarin Low vitamin K Haemophilia

Question 29

So as ALT is more specific to the liver than AST, which one is likely to be higher in acute liver injury?

Answer 29

ALT

Question 30

ALT is usually higher than AST in acute liver injury, unless the liver injury is caused by...?

Answer 30

Alcohol | Alcoholic liver disease

Question 31

What is the half life of albumin?

Answer 31

20 days

Question 32

What part of the liver do AST, ALT, albumin and INR relate to?

Answer 32

The parenchyma of the liver

Question 33

What are the two functions of bile?

Answer 33

Emulsifies fats | To get rid of the haem products

Question 34

What part of the liver do the ALP, GGT, serum bilirubin and bile acids relate to?

Answer 34

Cholestatic part (common hepatic duct, cystic duct and common bile duct)

Question 35

How long is the life of a red blood cell?

Answer 35

120

Question 36

What form is the bilirubin in when it is released from blood cells?

Answer 36

Unconjugated bilirubin (indirect)

Question 37

What does the liver do to bilirubin?

Answer 37

Conjugates it to conjugated bilirubin (direct)

Question 38

Where does the liver excrete conjugated bilirubin?

Answer 38

Into the intrahepatic ducts which then follow out of the liver to be extrahepatic ducts

Question 39

What form(s) of bilirubin can the kidney excrete?

Answer 39

Only the conjugated bilirubin

Question 40

If there is a blockage in the hepatic ducts, what will blood test show in terms of unconjugated and conjugated bilirubin?

Answer 40

Most likely show an increase in both

Question 41

If there is a blockage in the hepatic ducts, what will urine tests show in terms of unconjugated and conjugated bilirubin?

Answer 41

Conjugated bilirubin is the only form of bilirubin to be excreted by the kidneys.

Question 42

What does bilirubinuria tell you about the nature of the elevated levels of bilirubin in the blood?

Answer 42

That the problem is either hepatic or post hepatic, not pre-hepatic. In pre-hepatic jaundice there is only an increase in the levels of unconjugated bilirubin (eg haemolysis)

Question 43

What are the three things that can cause a rise in ALP?

Answer 43

Cholestasis Pregnancy Bone disease (bone growth, eg Paget's disease)

Question 44

What is ALP?

Answer 44

Alkaline phosphotase is an inducable enzyme which is released by biliary ductal cells of the intrahepatic bile ducts in liver damage.

Question 45

What is GGT?

Answer 45

Gamma-glutamyltransferase

Question 46

What causes a rise in GGT?

Answer 46

Cholestasis | Alcohol

Question 47

Does bone disease increase GGT?

Answer 47

No

Question 48

What is Gilbert's syndrome?

Answer 48

Most common (5% of population) hereditary cause of increased bilirubin. The cause of this hyperbilirubinemia is the reduced activity of the enzyme glucuronyltransferase, which conjugates bilirubin and a few other lipophilic molecules

Question 49

In Gilbert's syndrome, is there an increase in unconjugated or conjugated bilirubin?

Answer 49

Unconjugated

Question 50

In Gilbert's syndrome, is there an increase in ALP?

Answer 50

No.

Question 51

In hepaticellular jaundice, is there an increase of unconjugated or conjugated bilirubin in the blood?

Answer 51

Both. there is usually interference in all major steps of bilirubin metabolism—uptake, conjugation and excretion. However, excretion is the rate-limiting step, and usually impaired to the greatest extent. As a result, conjugated hyperbilirubinaemia predominates.

Question 52

In an acute infection of hepatitis A virus, what will liver function tests reveal?

Answer 52

Increased ALT Increased AST ALT increased more than AST Maybe increased INR

Question 53

What do you look for in the blood in order to make a diagnosis of hepatitis A?

Answer 53

IgM anti-hepatitis A

Question 54

In an acute infection of hepatitis B virus, what will liver function tests reveal?

Answer 54

Increased ALT Increased AST ALT increased more than AST Maybe increased INR

Question 55

What do you look for in the blood in order to make a diagnosis of hepatitis B?

Answer 55

Hepatitis B surface antigen IgM Hepatitis B surface antibody IgM Hepatitis B core antibodies

Question 56

In an acute infection of hepatitis C virus, what will liver function tests reveal?

Answer 56

Increased ALT Increased AST ALT increased more than AST Maybe Increased INR

Question 57

What do you look for in the blood in order to make a diagnosis of hepatitis A?

Answer 57

IgM anti-hepatitis A

Question 58

What do you look for in the blood in order to make a diagnosis of hepatitis B?

Answer 58

Hepatitis B surface antigen IgM Hepatitis B surface antibody IgM Hepatitis B core antibodies

Question 59

What do you look for in the blood in order to make a diagnosis of hepatitis C?

Answer 59

IgM anti-hepatitis C | Hepatitis C RNA

Question 60

In acute liver injury as a result of alcohol, what will liver function tests reveal?

Answer 60

Slightly increased ALT Slightly increased AST ALT and AST are raised about the same or AST could be higher Maybe increased INR

Question 61

In an acute bout of ischaemic liver injury, what will liver function tests reveal?

Answer 61

Huge elevation in ALT very sudden Huge elevation in AST Increased INR

Question 62

How will liver function tests of someone with chronic hepatitis B differ from someone with an acute infection of hepatitis B?

Answer 62

They will be similar but ALT and AST won't be as raised in the chronic case. There will most likely be an increased INR in the chronic case Albumin may be low in the chronic case

Question 63

How will liver function tests of someone with chronic hepatitis C differ from someone with an acute infection of hepatitis C?

Answer 63

They will be similar but ALT and AST won't be as raised in the chronic case. There will most likely be an increased INR in the chronic case Albumin may be low in the chronic case

Question 64

In someone suffering from non-alcohol steatohepatitis (NASH/fatty liver disease), what will liver function tests reveal?

Answer 64

Increased ALT Increased AST ALT increased more than AST Low albumin

Question 65

In someone suffering from alcoholic liver disease, what will liver function tests reveal?

Answer 65

Increased AST Increased ALT AST increased more than ALT Low albumin

Question 66

In someone suffering from autoimmune hepatitis, what will liver function tests reveal?

Answer 66

Increased ALT Increased AST ALT increased more than AST Low albumin

Question 67

What do we look for in the blood in order to make a diagnosis of autoimmune hepatitis?

Answer 67

Anti-smooth muscle antibody

Question 68

In someone suffering from hereditary haemochromatosis, what will liver function tests reveal?

Answer 68

Increased ALT Increased AST Low albumin

Question 69

What do we look for in the blood in order to make a diagnosis of haemochromatosis?

Answer 69

Serum ferritin > 1000 | Low or normal Total iron binding capacity

Question 70

What is hereditary haemochromatosis?

Answer 70

An autosomal recessive genetic disease (found on chromosome 6) in which increased intestinal absorption of iron causes accumulation in tissues, especially the liver, which may lead to organ damage. Other organs that may be affected by iron deposits include the pancreas, joints, heart, skin and gonads.

Question 71

In someone suffering from Wilson's disease, what will liver function tests reveal?

Answer 71

Increased ALT Increased AST Low albumin Low ALP

Question 72

What sign seen on examination might indicate that someone has Wilson's disease?

Answer 72

Kayser-Fleischa rings in their eyes

Question 73

What do we look for in the blood in order to make a diagnosis of Wilson's disease?

Answer 73

Low ceruloplasmin | Low ALP

Question 74

In someone suffering from alpha 1 antitrypsin deficiency, what will liver function tests reveal?

Answer 74

Slightly increased ALT | Slightly increased AST

Question 75

What will be seen in a histological assessment of liver biopsy in someone with liver disease as a result of alpha 1 antitrypsin deficiency?

Answer 75

PAS positive granules

Question 76

What do we look for in the blood in order to make a diagnosis of alpha 1 antitrypsin deficiency?

Answer 76

Low levels of alpha-1AT

Question 77

In someone suffering from primary biliary cirrhosis, what will liver function tests reveal?

Answer 77

``` Increased ALP Increased bilirubin (but later in the disease) ```

Question 78

In someone suffering from primary sclerosing cholangitis, what will liver function tests reveal?

Answer 78

Increased ALP | Increased bilirubin

Question 79

In someone suffering from large bile duct obstruction, what will liver function tests reveal?

Answer 79

Increased ALP | Increased bilirubin

Question 80

What is the classic history of a patient with large bile duct obstruction?

Answer 80

Pain Fever Jaundice